Defining the histopathological changes induced by nonablative radiofrequency treatment of faecal incontinence--a blinded assessment in an animal model.

AIM: Nonablative radiofrequency (RF) sphincter remodelling has been used to treat gastro-oesophageal reflux disease (GERD) and faecal incontinence (FI). Its mechanism of action is unclear. We aimed to investigate the histomorphological and pathophysiological changes to the internal and external anal sphincter (IAS and EAS) following RF remodelling. METHOD: An experimental FI model was created in 12 female pigs: eight underwent RF 6 weeks following induction of FI (FI+RF) and four were untreated (UFI). Four animals served as controls (CG). Two blinded pathologists examined all haematoxylin and eosin and trichrome stained slides. RESULTS: Compared with the UFI group, histological examination of the IAS in the FI+RF group demonstrated an increased smooth muscle (SM)/connective tissue ratio (77.2 vs 68.1%, P < 0.05) and increased collagen I compared with collagen III content (67.2 vs 54.9%, P < 0.001). The RF+FI group exhibited greater SM bundle thickness compared with the UFI group (SM width 486.93 vs 338.59 µm, P < 0.01; height 4384.4 vs 3321.0 µm, P < 0.05). The EAS of the FI+RF animals showed a significantly higher type I/II fibre ratio (33.5 vs 25.2%, P = 0.023) and fibre type I diameter (67.2 vs 59.7 µm, P < 0.001) compared with the UFI group. Post-RF manometry showed higher basal (18.8 vs 0 mmHg, P < 0.001) and squeeze (76.8 vs 12.4 mmHg, P < 0.05) anal pressures. After RF treatment, the number of interstitial cells of Cajal was significantly reduced compared with the UFI and CG groups [0.9 (FI+RF) vs 6.7 (UFI) vs 0.7 (CG) per mm(2) , P < 0.001]. CONCLUSION: In an animal model nonablative RF appeared to induce morphological changes in the IAS and EAS leading to an anatomical state reminiscent of normal sphincter structure.

Doppler guided haemorrhoidal arterial ligation with recto-anal-repair (RAR) for the treatment of advanced haemorrhoidal disease.

OBJECTIVE: A modification of Doppler guided haemorrhoidal artery ligation (DGHAL) to include the addition of recto-anal repair is reported. Preliminary results of function and safety of third and fourth degree haemorrhoidals are given. METHOD: Thirty patients underwent DGHAL combined with recto-anal-repair (RAR). Each had rectal examination, anorectal manometry and Quality of Life assessment before and 3 months after the procedure. RESULTS: Twenty-nine patients were included in the final analysis. There were three (10.34%) patients of intra-operative and one (3.45%) of postoperative bleeding. Three months after RAR (17.24%) patients with minor residual mucosal prolapse were detected, three (10.34%) patients reported residual symptoms. There was no case of recurrent bleeding. Anal manometry at 3 months after RAR was significantly lower than before the procedure (P < 0.05). One (3.45%) patient reported occasional soiling 3 months after RAR. CONCLUSION: Recto-anal-repair is safe in treating third and fourth degree haemorrhoids with no major complications and low rate of residual disease.

Superiority of preemptive analgesia with intraperitoneal instillation of bupivacaine before rather than after the creation of pneumoperitoneum for laparoscopic cholecystectomy: a randomized, double-blind, placebo-controlled study.

BACKGROUND: This study aimed to evaluate the optimal timing of preemptive analgesia with bupivacaine peritoneal instillation in a prospective, randomized, double-blind, placebo-controlled trial. METHODS: In this study, 120 patients qualified for laparoscopic cholecystectomy were randomized to four groups. Group A received 2 mg/kg of bupivacaine in 200 ml of normal saline before creation of pneumoperitoneum. Group B received 2 mg/kg of bupivacaine in 200 ml of normal saline after creation of pneumoperitoneum. Group C received 200 ml of normal saline before creation of pneumoperitoneum. Group D received 200 ml of normal saline after creation of pneumoperitoneum. Local wound infiltration with bupivacaine was used before skin incisions. The primary end points of the study were postoperative pain intensity on a visual analog scale and incidence of shoulder tip pain. The secondary end points included the latency of nurse-controlled analgesia activation, the analgesia request rate, and analgesic consumption. RESULTS: Significantly lower visual analog scores were observed in group A versus groups C and B versus group D during the initial 48 and 24 h, respectively. The patients in group A versus group B reported significantly lower pain at 4 h (p < 0.001) and 8 h (p = 0.003) postoperatively, but the difference was not significant after 12, 24, and 48 h. None of the group A patients reported shoulder tip pain, whereas it was reported by 3 patients in group B, 6 patients in group C, and 7 patients in group D (p < 0.01). The latency of nurse-controlled analgesia activation was 426.8 +/-57.2 min in group A, as compared with 307 +/- 39.8 min in group B, 109.3 +/- 51 min in group C, and 109 +/- 46.5 min in group D (p < 0.001). A significantly lower analgesia request rate was observed in group A versus C, as compared with group B versus D, throughout the entire study period (p < 0.05). CONCLUSIONS: Preemptive analgesia with bupivacaine peritoneal instillation is much more effective for pain relief if used before creation of pneumoperitoneum. Although the effect of bupivacaine peritoneal instillation is also noticeable when used after creation of pneumoperitoneum, it confers significantly lower benefits.

Intrathecal baclofen suppresses central pain in patients with spinal lesions. A pilot study.

OBJECTIVE: To assess the efficacy of acute intrathecal (i.t.) baclofen on chronic, dysesthetic, and spasm-related pain (SRP) among patients with spinal spasticity [i.e., multiple sclerosis (MS), spinal cord injury (SCI), transverse myelitis (TMy)]. DESIGN: Double-blind, randomized, and placebo (vehicle) controlled trials (n = 7), and nonrandomized, nonblinded trials (n = 2). SETTING: In-patient program at Samaritan Rehabilitation Institute, Phoenix, Arizona, U.S.A. PATIENTS: MS (n = 4), spinal cord compression (n = 1), and TMy (n = 2) in the double-blind trial, and SCI (n = 2) in the nonblinded trial; all had chronic spinal lesions and function-limiting spasticity refractory to oral medications, including baclofen (p.o.). INTERVENTIONS: i.t. baclofen (50 micrograms) in 1 ml preservative-free normal saline into the L1-2 interspace. OUTCOME MEASURES: Electromyographic (EMG) activity; intravesical and intraurethral pressures; Ashworth Scale and tendon response values; visual analog scales for describing dysesthetic pain intensity; and threshold/EMG relationships after controlled pinch as an indication of nociceptive pain. RESULTS: i.t. baclofen (a) caused marked reduction of segmental reflexes before suppression of intersegmental reflexes; (b) significantly suppressed dysesthetic pain and SRP with temporal dissociation; and (3) did not influence pinch-induced and musculoskeletal (low back) pain. CONCLUSIONS: The suppressive action of i.t. baclofen on spontaneous and evoked (allodynia) dysesthetic pain suggests that a dysfunctional spinal gamma-aminobutyric acidB receptor system, including functional supersensitivity, is associated with the phenomenon of central pain among patients with spinal lesions. Temporal dissociation regarding the action on dysesthetic pain and SRP suggests that disparate central mechanisms subserve the two clinical states.

A prospective randomized trial on comparison of low-pressure (LP) and standard-pressure (SP) pneumoperitoneum for laparoscopic cholecystectomy.

AIM: This study aimed to investigate the advantages and disadvantages of LP (7 mmHg) in comparison to SP (12 mm Hg) pneumoperitoneum in a prospective randomized clinical trial. MATERIALS AND METHODS: 148 consecutive patients qualified for laparoscopic cholecystectomy (LC) due to uncomplicated symptomatic gallstones were randomized to either SPLC or LPLC. All the procedures were performed by the same experienced team of surgeons. The statistical analysis included sex, mean age, body mass index, ASA grade, operative time, complication rate, conversion rate, postoperative pain assessed by the Visual Analogue Scale of Pain (VAS) including the incidence of shoulder-tip pain, postoperative hospital stay, recovery time, and the quality of life (QOL) within 7 days following the operation. p <0.05 was considered as indicative of significance. RESULTS: Neither conversion to an open procedure nor major complications occurred in either group. The operative time was similar in both groups (LP 55.7 +/- 8.6 min vs SP 51.9 +/- 8.3 min). The mean postoperative pain score was 6.18 +/- 3.48 lower after LP than SPLC and the difference amounted to 22.2% (p <0.005). The incidence of shoulder-tip pain was 2.1 times lower after LP than SPLC (p <0.05). QOL within 7 days following the operation was remarkably better after LPLC than after SPLC (p <0.01). CONCLUSIONS: LP pneumoperitoneum is superior to SP pneumoperitoneum in terms of lower postoperative pain, a lower incidence of shoulder-tip pain, and a better QOL within 5 days following the operation. LP should be used for LC in cases of uncomplicated symptomatic gallstones as a recommended procedure as long as an adequate exposure is obtained with this technique.

Low-pressure pneumoperitoneum combined with intraperitoneal saline washout for reduction of pain after laparoscopic cholecystectomy: a prospective randomized study.

BACKGROUND: We designed a prospective randomized clinical trial to investigate whether intraperitoneal saline washout combined with a low-pressure pneumoperitoneum (LPSW) was superior to low-pressure pneumoperitoneum (LP) alone as a means of reducing postoperative pain and analgesic consumption in the early recovery period after laparoscopic cholecystectomy (LC). METHODS: A total of 124 consecutive patients undergoing LC due to uncomplicated symptomatic gallstones were randomized to the LP or LPSW group. In the LPSW group, normal saline at body temperature (25 ml/kg of body weight) was irrigated under the diaphragm. The fluid was evacuated via the passive-flow method through a 16-F closed drain left under the liver for 24 h. We then assessed the intensity of total abdominal postoperative pain using the Visual Analogue Scale (VAS), including the incidence of shoulder-tip pain (STP), total daily analgesia demand rate, analgesic consumption. Quality of life (QOL) within 7 days after the operation was assessed using the Medical Outcomes Study Short Form 36 Health Survey (SF-36). A p value of <0.05 was considered significant. RESULTS: The mean postoperative pain score was lower by 2.64 +/- 0.86 in the LPSW; the difference equaled 9.64% (p < 0.05). The incidence of STP was lower in the LPSW group (LP 11.29% vs LPSW 1.6%; p = 0.028). The analgesia demand rate was remarkably lower in LPSW vs LP within 24 and 48 h postoperatively (70.96% vs 90.32%; p = 0.006 and 64.51% vs. 83.87%; p = 0.013, respectively). After LPSW vs LP, QOL was better in terms of physical functioning, role limitations due to physical problems, and bodily pain (90.32% vs 77.42%; p = 0.05, 90.32% vs 75.8%; p = 0.03, 91.93% vs 74.19%; p = 0.008, respectively). CONCLUSION: In terms of lower postoperative pain and a better QOL within the early recovery period, LPSW is superior to LP alone. The saline washout procedure should be recommended during LC because it is a simple way to reduce pain intensity, even after LP operations.

Decreased incidence of scoliosis in hearing-impaired children. Implications for a neurologic basis for idiopathic scoliosis.

STUDY DESIGN: A retrospective survey of the incidence of positive scoliosis screenings in schools for the hearing impaired was performed. OBJECTIVES: The incidence rate of scoliosis in a population with a high incidence of vestibular dysfunction was compared with the national normative incidence rate. The comparison was done to investigate the contribution of the vestibular system to scoliosis. SUMMARY OF BACKGROUND DATA: Several reports have emphasized a possible neural etiology to idiopathic scoliosis. Based on the experimental hypothesis that an altered vestibular processing is critical for the production of scoliosis, 100 schools for the hearing impaired were surveyed to determine their incidence of positive screenings for scoliosis. Because it is known that hearing-impaired children have a high incidence of vestibular dysfunction, it was hypothesized that their screening incidence would change if the vestibular system contributed to idiopathic scoliosis. METHODS: Surveys were sent to 100 schools for the hearing impaired asking for their most recent scoliosis screening data. RESULTS: Of the 40 surveys returned, 28 schools for the hearing impaired conducted routine scoliosis screenings, of which 17 had demographics representative of the national norms. Of the 3127 students screened at these 17 schools, 1.2% of the students screened positive for scoliosis. This is significantly less than national incidence rate of 4%-10%. CONCLUSION: The results suggested that hearing-impaired students may be a population that is protected from idiopathic scoliosis by a neural dysfunction. These data strongly suggest that idiopathic scoliosis has a neural etiology.

Use of augmented sensory feedback to achieve symmetrical standing.

Ambulatory patients with hemiparesis were given auditory feedback of weight bearing on the involved leg in order to achieve symmetrical standing. A device for augmented sensory feedback, the Limb Load Monitor, was used for the training. Patients who could correct their limb loading pattern during the first treatment session learned to achieve symmetrical standing. Results are also related to the magnitude of weight bearing on the involved limb and the side on which the lesion occurs. These findings suggest that the patients utilized the feedback signal to control an inherent activity.

Pancreatic carcinoma-induced changes in gastric myoelectric activity and emptying.

BACKGROUND/AIMS: Twenty patients with histologically confirmed pancreatic carcinoma without any endoscopic evidence of gastroduodenal obstruction were included in the study. The aim was to determine changes in gastric myoelectric activity and liquid/solid gastric emptying induced by pancreatic tumor. METHODOLOGY: According to TNM/UICC classification patients were divided into two groups A (T2) and B (T3) due to extent of tumor invasion (mainly to retroperitoneum space). In all patients electrogastrography, solid and liquid gastric emptying tests were performed. RESULTS: In the majority of patients of groups A and B the most commonly reported complaints included upper abdominal pain (60% vs. 80%) and icterus (80% vs. 60%). Dyspeptic symptoms were observed in 40% patients of group A and 90% in group B. In group electrogastrography recordings showed dysrhythmia patterns, mostly bradygastria, in 50% of group A patients and in 80% of group B. Liquid/solid gastric emptying were delayed in 20/40% of group A patients and 50/80% of group B. Disorders of gastric myoelectric activity and emptying correlated with tumor stage and location across analyzed groups but not with histology and hyperbilirubinemia levels. CONCLUSIONS: It was observed that solid gastric emptying is affected earlier compared to liquid gastric emptying. Delayed gastric emptying may be attributed to gastric dysrhythmia and/or abdominal pain but not mechanical effects of tumor growth that occur during the course of disease.

[Stomach electrostimulation--new possibility for treating gastroparesis]. / Elektrostymulacja zoladka--nowa mozliwosc leczenia gastroparezy.

This paper presents a large range of methods of human gastric pacing. Based on our own experience and literature authors discuss a variety of pacing models, current parameters and place of stimulation. We described a new method of intragastric stimulation as a method of treatment of postoperative, pharmacotherapy resistant gastroparesis. Five patients were included in to the study (3 male and 2 female). The current parameters were as follow: square profile, amplitude 2V (2mA), frequency 6 ips.p.m., duration 3 hours. Two electrodes located on nasogastric catheter (external diameter 1.5 mm) were placed in antral region of the stomach and connected to the computer preprogrammed stimulator. Electrostimulation was accompanied by the continuous cutaneous EGG monitoring (Synectics Sweden). Excellent results were obtained in 3 patients (60%) with disappearance of symptoms, rumbling, normalization in gastric myoelectric rhythm (2-4 cpm > 85%) and with increase in amplitude (average 250%). In one patient with the gastrectasia, symptoms returned next day and stimulation had to be repeated for several days. In another one results were not satisfying. Authors conclude that gastric pacing has made tremendous progress fast developing method in last decade and in most patient is efficient for treatment postoperative gastroparesis.

[Current diagnosis of gastroduodenal reflux and biliary gastritis]. / Wspólczesna diagnostyka refluksu dwunastniczo-zoladkowego i zólciowego zapalenia zoladka.

Though primary and secondary duodenogastric reflux (DGR) have been accepted in the medical literature as separate clinical units, reliable and standardised methods of detection have not been known since long. Therefore, the role of DGR in the pathogenesis of upper GI tract diseases makes a problem. So far applied measurement techniques allow only indirect diagnosis of DGR, which is often unphysiological and not objective. These methods do not allow also quantitative evaluation. Unsatisfying results obtained with the use of these methods and further search for the effective system of 24-hour monitoring of bilirubin concentration, which is indirect marker of alkaline reflux Bilitec 2000 is the most physiologic technique of ambulatory recording of the retrograde duodenogastric reflux. It makes possible objective diagnosing of alkaline gastritis as a result of excessive exposure of gastric mucose to destructive effect of bile and pancreatic juice.

[Pathogenesis and significance of gastroduodenal reflux]. / Patogeneza i znaczenie refluksu dwunastniczo-zoladkowego.

For over a century duodenogastric reflux (DGR) has been considered the main cause of the primary or secondary alkaline gastritis. In the first case it occurred in patients who had not been operated earlier, in the latter one in those after surgery of stomach, duodenum, gallbladder and bile ducts. Since first time many reports of clinical and experimental studies have demonstrated destructive effect of pancreatic enzymes, bile acids and their by-products on stomach mucose producing in consequence non-specific histologic lesions. It has been also observed that duodenogastric reflux plays the basic role in the patho-genesis of gastritis and other GI tract diseases (gastric ulcer, reflux oesophagitis, progressing metaplasia or oesophageal and gastric cancer). As far as diagnosing of alkaline gastritis requires histologic confirmation, duodenogastric reflux brings many more problems. However, the progress in medicine and technology allow direct measurement of quality and quantity of this reflux.

[Preliminary results of dynamic gracilloplasty in the treatment of fecal incontinence]. / Wstepne wyniki zastosowania dynamicznej graciloplastyki w leczeniu nietrzymania stolca.

UNLABELLED: Transposition of the gracilis muscle and its continuous electrical stimulation became a widely accepted method for treatment of patients with severe fecal incontinence. This method introduced to clinical practice by Baeten, Williams and Cavina has also been applied in total anorectal reconstruction following abdominoperineal rectum resection due to rectal cancer. This paper describes our (limited so far) experience with dynamic gracilloplasty procedure in the treatment of fecal incontinence in six patients with injury of anal sphincters. Complete preoperative work up was based on the clinical symptoms of fecal incontinence evaluated in detail according to Jorge and Wexner Incontinence Scoring System and the clinicomanometric continence criteria according to Holscheider scale. Anorectal manometry, transanal endosono-graphy, defecography and barostat study were performed in each patient before and following surgery. Dynamic gracilloplasty procedure was performed according to the modified Baeten procedure--as a one stage procedure. Medtronic equipment (IPG Pulse Generator 3023) was applied for gracilis stimulation. Short term program of fast-to-slow muscle conversion was applied starting from the second week following surgery. Patients were prospectively evaluated after surgery in terms of clinical symptoms and anorectal physiology. Complete fecal continence was achieved in all patients during the first month following surgery. There were no serious postoperative complications. It was shown during anorectal manometry that dynamic gracilloplsty could increase the anal sphincter pressure up to the range of healthy subjects, thus to prevent fecal leakage. The overall clinical and manometic results confirm the feasibility of anal dynamic gracilloplasty to restore fecal continence in patients with complete lost of sphincter function due to its traumatic injury or atresia. This technique deserves wider application also in Poland, since our initial results are encouraging. CONCLUSION: According to our limited experience dynamic gracilloplasty proved safe and effective procedure for the treatment end-stage fecal incontinence. Complete preoperative diagnostic work-up is essential for proper patients selection and surgical procedure should be performed in a specialised surgical center.

[Intraoperative manometry in laparoscopic antireflux procedures --indications, methods and clinical results]. / Sródoperacyjna manometria w laparoskopowych zabiegach antyreflusowych--wskazania, metodyka i wstepne wyniki kliniczne.

UNLABELLED: The aim of the study is evaluating the efficiency of intraoperative manometry during laparoscopic Nissen fundoplication and its ability to prevent postoperative complications. METHOD: Sixteen patients with Gastroesophageal Reflux Disease were included in the study. Clinical examinations, x-ray, endoscopy, pH-metry, and manometric studies were performed before, and 3-6 m.o. after surgery. Fourteen patients were undergoing Nissen fundoplication, and two "floppy Nissen" fundoplications due to the specific preoperative manometric indications. RESULTS: Postoperatively the mean proportion of time at pH < 4.0 on pH-metry decreased from 188 min. (range 96-263) to 8.5 min. (range 2-25). Mean number of reflux episodes significantly lowered after fundoplication from 18.9 (range 2-36) to 0.5 (range 0-3). Gastroesophageal junction mean pressure measured postoperatively reached 24.7 mmHg, and was significantly higher than preoperatively (8.9 mmHg). Mean length of LES increased from 1.2 cm (range 0.8-2.5) to 3.6 cm (range 2.4-4.6) postoperatively. CONCLUSIONS: Laparoscopic Nissen fundoplication assisted by the simultaneous continuous intraoperative manometry is feasible and effective procedure. Continuous LES pressure monitoring during laparoscopic fundoplication with simultaneous computer-video assisted display can be advised as an objective method of intraoperative evaluation of antireflux mechanism.